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| Information About Your Child/Teenager |
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| First Name: |
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| Last Name: |
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| Age: |
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| Health Care Number: |
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| Does your child/teen have a disability? |
Yes No |
| If yes, please explain: |
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| Does your child/teen use a wheelchair? |
No Electric Manual |
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| Does your child/teen require individual support? |
Yes No |
| Please explain: |
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Please describe how your child/teen communicates:
(e.g. signs, picture board, some words) |
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| Does your child/teen have any medical concerns we should know about?: |
Yes No |
If yes, please describe.
You must return to administer any medication. |
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| Does your child/teen have seizures? |
Yes No |
| If yes, please list: |
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| Does your child/teen have allergies? |
Yes No |
| If yes, please list: |
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| Does your child/teen require assistance with toileting? |
No Yes - Full
Yes - Partial |
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| Does your child/teen require assistance with eating? |
No Yes - Full
Yes - Partial |
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| Does your child/teen have other special needs or behavioural difficulties? |
No Yes |
| If yes, please explain: |
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| Is there any additional information we need to know in order to assist your child/teen to enjoy their weekend? Please remember, we want to provide a safe and fun environment so we ask that you provide as much information as possible. Thank you! |
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| Parent or Guardian |
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| First Name: |
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| Last Name: |
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| Home Phone: |
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| Cell Phone: |
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| Pager: |
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| Email: |
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